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cardio.acute-hf.cardiorenal.v1

Acute HF — Type-1 cardiorenal syndrome (ADHF + AKI)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.acute-hf.core.v1 — Type-1 cardiorenal syndrome (acute HF + concurrent AKI driven by low CO + venous congestion). Specializes sequential nephron blockade per ADVOR (acetazolamide PMID 36027564) + CLOROTIC (HCTZ PMID 36461706); tolerates ≤30% Cr rise per CARRESS-HF (PMID 23131078) which showed UF NOT superior to stepped pharmacologic; HOLDS ACEi/ARNI temporarily during severe Cr rise then restarts at lower dose; CONTINUES SGLT2i if eGFR >20 per EMPULSE (PMID 35347356) for reno-cardiac protection. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (cardiorenal specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (3)

  • lab_abnormality
    Cr rise ≥0.3 mg/dL or ≥50% from baseline during ADHF treatment → Type-1 CRS (Ronco 2008; KDIGO AKI)
    cr_rise_during_adhf_admission
  • symptom
    ADHF + oliguria <0.5 mL/kg/h despite adequate diuretic dose → cardiorenal phenotype
    adhf_with_oliguria
  • history
    Persistent congestion + escalating loop diuretic + worsening renal function → sequential blockade indication
    diuretic_resistance_with_worsening_renal

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients more susceptible to cardiorenal injury + slower recovery
  • sbprequired
    vital • used at RED_FLAGS
    BP guides decongestion vs perfusion priority; SBP <90 + AKI = SCAI C+ shock with renal involvement
  • creatininerequired
    lab • used at CONTEXT
    Defines AKI severity (KDIGO stages); trend during diuresis. Tolerate ≤30% rise per CARRESS-HF if congestion improving
  • bunrequired
    lab • used at CONTEXT
    BUN/Cr ratio + urea-driven prognosis; rising BUN with stable Cr suggests pre-renal congestion phenotype
  • potassiumrequired
    lab • used at CONTEXT
    Sequential nephron blockade + MRA + ARNI dosing risk; K monitoring critical in CRS
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Decongestion target marker; >30% drop predicts renal recovery
  • lung_us
    imaging • used at MONITORING
    B-line resolution as objective decongestion endpoint when oliguric
  • ivc_us
    imaging • used at MONITORING
    IVC diameter + collapsibility for congestion tracking when urine output unreliable
  • home_loop_doserequired
    history • used at TREATMENT
    IV escalation must be 2-2.5× home dose per DOSE; cardiorenal often diuretic-resistant

12-phase flow (10)

  1. 1FRAME
    Type-1 CRS = acute HF + concurrent AKI; venous congestion (high CVP) is dominant mechanism; decongestion remains priority despite moderate Cr rise per CARRESS-HF
    inputs: creatinine
    advance: Type-1 CRS confirmed
  2. 2ENTRY
    IV loop diuretic at 2-2.5× home dose per DOSE; assess response at 2h; do NOT default to UF (CARRESS-HF showed no superiority)
    inputs: home_loop_dose
    advance: IV diuretic dosed
  3. 3CONTEXT
    Baseline Cr (3-6 mo prior), home diuretic regimen, ACEi/ARB use, NSAIDs, contrast exposure, nephrotoxin screen
    inputs: age, creatinine, bun, potassium
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock + AKI (SCAI C+ with renal hypoperfusion → MCS consideration); severe hyperK >6 with EKG changes; metabolic acidosis with anion gap; refractory pulmonary edema
    inputs: sbp, potassium
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    BMP, NT-proBNP, urinalysis with sediment, urine Na/Cr (FENa <1% suggests pre-renal/congestion phenotype), renal US to exclude obstruction, lung US for congestion endpoint
    inputs: nt_probnp, creatinine
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If UOP <0.5 mL/kg/h after 2h on adequate IV loop → sequential blockade (acetazolamide per ADVOR OR HCTZ per CLOROTIC OR metolazone); reassess every 6-12h
    inputs: home_loop_dose
    advance: sequential blockade decision made
  7. 7TREATMENT
    IV loop diuretic 2-2.5× home dose; acetazolamide 500 mg IV daily × 3 (ADVOR) for diuretic-resistant or persistent metabolic alkalosis; HCTZ or metolazone for refractory; HOLD ACEi/ARB temporarily if Cr rise >50%; CONTINUE SGLT2i (eGFR >20) per EMPULSE — reno-cardiac protective; CONTINUE BB unless hypotensive; do NOT add nephrotoxins
    inputs: creatinine, potassium
    actions: protocol.cardiogenic_shock
    advance: decongestion strategy active + RAAS gating documented
  8. 8DISPOSITION
    Floor with daily BMP if mild AKI; CICU if shock or refractory diuretic resistance requiring inotropes
    advance: unit assigned
  9. 9MONITORING
    Daily weight, hourly UOP, BMP q12h during diuresis, NT-proBNP trend, lung US/IVC for objective congestion when oliguric, daily review of nephrotoxins
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring cadence active
  10. 10FOLLOWUP
    Restart ACEi/ARB or ARNI at lower dose once euvolemic + Cr stable; STRONG-HF cadence; nephrology clinic if AKI did not fully resolve; SGLT2i continuation
    advance: GDMT restart plan + STRONG-HF + nephrology booked